Manage an assigned patient panel, addressing specialized needs based on individual conditions and care goals.
Collaborate with physicians, APPs, and interdisciplinary team members to coordinate holistic care.
Perform assessments, create care plans, and monitor effectiveness to ensure high-quality outcomes.
Evergreen Nephrology partners with nephrologists to transform kidney care through a value-based, person-centered approach. They focus on improving patient outcomes and quality of life in an innovative and evolving environment.
Manage the healthcare journey of kidney disease patients in the Compassionate Care Program, focusing on advance care planning and goals of care discussions.
Collaborate with physicians and interdisciplinary teams to coordinate transitions to hospice or ongoing care based on patient preferences.
Educate internal and external partners on identifying and referring patients to the program.
Evergreen Nephrology partners with nephrologists to transform kidney care through a value-based, person-centered, holistic approach. As a startup, it is committed to improving patient outcomes and quality of life with an innovative and evolving culture.
Provide short-term, telephonic care management to high-risk patients in the 30 days after hospital discharge, focusing on preventing avoidable readmissions.
Conduct comprehensive assessments, develop individualized care plans, educate patients and caregivers, and coordinate with interdisciplinary teams and community resources.
Serve as a patient advocate, helping navigate complex care journeys while working in a remote, metrics-driven environment.
Our partner is a healthcare organization that provides transitions of care support for high-risk patients post-hospital discharge. They operate in a collaborative, technology-enabled environment focused on measurable outcomes and exceptional patient experiences, and they are hiring for this role through Jobgether, an AI-powered job matching platform.
Lead a team delivering longitudinal, patient-centered care for complex chronic conditions.
Oversee daily operations of the care management team to ensure consistent, proactive care.
Drive program performance against KPIs and quality metrics to improve patient outcomes.
Evergreen Nephrology partners with nephrologists to transform kidney care through a value-based, person-centered approach. They are committed to improving patient outcomes and quality of life, and they foster a culture of innovation and collaboration.
Conduct monthly clinical check-ins and build ongoing relationships with patients and caregivers.
Perform structured symptom assessments and escalate clinical concerns using licensed judgment.
Collaborate with providers and care teams to ensure accurate documentation and care coordination.
Evergreen Nephrology partners with nephrologists to transform kidney care through a value-based, person-centered approach. They are building a team focused on improving outcomes for kidney disease patients with a supportive culture.
Manages a defined patient panel, ensuring quality, cost, and outcome accountability through collaboration and comprehensive care planning.
Obtains patient history, performs exams, orders diagnostic tests, and formulates plans for chronic conditions like CKD and heart failure.
Accurately documents diagnoses for risk adjustment and care gaps, while serving patients across home, telehealth, and clinic settings.
Strive Health transforms chronic conditions by identifying risk earlier and coordinating thoughtful care to reduce emergency visits and improve patient outcomes. The company fosters a passionate, one-team culture where Strivers care deeply about making an impact and elevating the everyday.
Manage care for high-risk members by identifying needs and coordinating clinical, community, and in-network resources.
Perform utilization management reviews, ensure quality oversight, and support accreditation readiness.
Collaborate with multidisciplinary teams to analyze member outcomes and drive continuous improvement.
They are a health plan focused on improving outcomes for high-risk members through care coordination and quality initiatives. Their team values collaboration, clinical excellence, and mission-driven work to enhance community health.
Manage a defined patient caseload while overseeing the clinical performance and compliance of an assigned team of Care Managers.
Conduct proactive outreach, device data review, care plan updates, and care coordination consistent with team standards.
Lead client-facing engagements, performance reviews, and escalation calls, representing Welby Health with clinical authority.
Welby Health is a San Diego-based healthcare organization that transforms complex condition management through technology-enabled care coordination and data-driven insights. The company partners with physicians and health systems to deliver scalable solutions improving quality of care.
Strategically assess, plan, and facilitate comprehensive care across the continuum for high-risk patients.
Collaborate with physicians, nursing, insurers, and post-acute providers to ensure timely transitions.
Work remotely from California, using provided equipment, with potential weekend/holiday coverage.
Dignity Health Management Services provides integrated managed care administrative and clinical services to medical groups, hospitals, and health plans. It is part of CommonSpirit Health, one of the largest nonprofit health systems in the US, with a focus on coordinated patient care and community health.
Build meaningful relationships with patients and families to create personalized care plans addressing medical, behavioral, and social needs.
Coordinate care across providers and settings while educating and empowering members to navigate the healthcare system confidently.
Collaborate with an interdisciplinary team, using data for insight and maintaining compliance while prioritizing compassion and connection.
Guidehealth is a data-powered, performance-driven healthcare company using AI and predictive analytics to improve healthcare affordability and patient outcomes. It is a physician-led, fully remote organization with a collaborative, agile culture focused on innovation and empathy.
Supervise a team of 10-15 ECM staff to ensure high-quality care management services.
Oversee client outreach, enrollments, and Individual Care Plans, serving as escalation point.
Drive team to meet KPIs, collaborate on process improvements, and provide clinical oversight 30% of the time.
Vynca provides comprehensive care for individuals with complex needs, focusing on more quality days at home. The company fosters a close-knit community culture guided by core values of Excellence, Compassion, Curiosity, and Integrity.
You perform telephonic outreach to enroll and engage patients in the clinical program.
You develop and implement care plans addressing unique patient needs in collaboration with nurse care managers.
You connect patients to community resources such as housing, transportation, and food security to address social determinants of health.
Evergreen Nephrology partners with nephrologists to transform kidney care through a value-based, person-centered, holistic approach. They are a growing company committed to improving patient outcomes and quality of life, fostering a collaborative and innovative culture.
Conduct patient outreach and enrollment for chronic care management programs.
Coordinate communication between patients, providers, and healthcare partners.
Document patient interactions and ensure compliance with Medicare billing requirements.
Evergreen Nephrology partners with nephrologists to transform kidney care through a value-based, person-centered approach. They are committed to improving patient outcomes and quality of life, with a culture of innovation and compassion.
Manage high volume of outbound and inbound new patient onboarding calls.
Build trust with patients and clinical care team through exceptional omnichannel customer service.
Collaborate with interdisciplinary care team to schedule visits and support patient goals.
Evergreen Nephrology partners with nephrologists to transform kidney care through a value-based, person-centered approach. They are a growing, innovative organization focused on interdisciplinary teamwork and improving patient outcomes.
Provide clinical education, focused interventions, and care transition support for members with low-acuity needs.
Conduct in-person and virtual clinical exams, medication reconciliation, and chart reviews.
Triage referrals and collaborate with care team to ensure timely follow-up and handoffs.
Cityblock Health is a tech-driven provider for communities with complex needs, offering personalized primary care, behavioral health, and social services. Founded in 2017 and backed by Alphabet, the company has a diverse, inclusive culture and is growing rapidly.
Analyze health plan reports and clinical data to identify members eligible for case management.
Conduct comprehensive telephonic and virtual assessments to evaluate medical, behavioral, and social needs.
Develop, implement, and monitor individualized care plans with measurable goals and interventions.
Duly Health and Care is a physician-led medical group offering a connected network of primary and specialty care, surgery centers, imaging, lab, and therapy services. They foster a collaborative culture centered on putting patients first and supporting team growth.
Monitor and interpret patient vitals, assessments, and alerts within Welby Health’s platform to provide timely, evidence-based guidance and escalate clinically significant findings.
Develop, implement, and adjust individualized care plans addressing both clinical and social needs, coordinating with physicians, specialists, and community resources.
Deliver patient education and coaching via telephone and secure messaging, empowering patients to manage chronic conditions and build sustainable health habits.
Welby Health is a San Diego-based healthcare organization committed to transforming the way complex conditions are managed. The company leverages technology and clinical expertise to improve patient outcomes and practice efficiency.
Provides comprehensive remote patient support and care coordination to optimize health outcomes in a virtual environment.
Collaborates with physicians and healthcare team members to assess patient status and develop personalized care plans.
Monitors patient progress, educates on disease processes, and advocates for patient needs to ensure high-quality care.
St. Joseph's Hospital and Medical Center is a 571-bed not-for-profit hospital in Phoenix, Arizona, offering quaternary care, medical education, and research. It is a nationally recognized center with over 125 years of history, consistently named an outstanding place to work.
Coordinate and provide care that is timely, effective, and member-centric while following HMO processes.
Manage case assignments including outreach, documentation, monitoring for case progression, and case closure.
Assist members in reaching wellness by addressing barriers, social determinants, and psychosocial issues.
Guidehealth is a data-powered healthcare company dedicated to making great healthcare affordable and improving patient outcomes. It is a physician-led, performance-driven organization with a culture of empathy, accountability, and continuous learning.
Conduct comprehensive clinical assessments and provide triage, support, and education to cancer patients via phone and email.
Collaborate with nurse leaders and medical directors to ensure alignment with clinical protocols and best practices.
Establish trusting relationships with members and their care network, prioritizing empathy and active listening in every interaction.
Thyme Care is a value-based oncology care enabler that partners with health plans, providers, and employers to improve outcomes and lower costs for people with cancer. It is a tech-native organization with a mission-driven culture focused on human connection and innovation.